ReviewRisk factors for cardiovascular disease in women
Section snippets
Lipids
In women, as in men, the association between cholesterol and LDL-cholesterol with increased cardiac risk is beyond dispute as are the benefits of its reduction in high-risk individuals. The follow-up study by the Lipid Research Clinic demonstrated that low HDL-C was the most significant predictor of death from IHD in women, after being adjusted for age [12].
The Swedish National guidelines propose a total cholesterol target of less than 5 mmol l−1 for primary prevention and less than 4.5 mmol l−1
Hypertension
Meta-analysis of prospective data collected from over 1 million adults (40–69 years) has shown that a 20-mmHg systolic or a 10-mmHg diastolic increase in usual blood pressure doubles mortality from CHD [22]. A 3-fold increase in CHD and stroke is found in women with a systolic blood pressure (BP) >185 mmHg as compared with women with BP <135 mmHg [23]. The JNC VII (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends BP <140/90 mmHg in all
Smoking
That smoking predisposes to atherosclerosis is not disputed [24], [25]. In the Nurses’ Health Study including over 120 000 healthy nurses, four to five cigarettes a day almost doubled the risk and 20 cigarettes a day increased the risk 6 times [26]. The reduction in male smokers has been a public health achievement; unfortunately the number of women smokers (initially lower than men) has not declined to the same extent, and this is particularly true for younger women leading to significant
Diabetes
Cardiovascular events are the leading cause of death especially in type II diabetes [29]. Diabetic women have a 3- to 5-fold increased risk of developing CVD compared with men [30].
The INTERHEART study estimated that 15% of heart attacks in Western Europe are due to diagnosed diabetes [2]. The corresponding figure in Central and Eastern Europe is 9%.
In the Nurses’ Health Study, CHD mortality in women with diabetes was 8.7 times higher than in non-diabetics, and in addition, those who had a
Obesity
Worldwide, 30% of women are now overweight (men 40%) and 27% are obese (men 24%) [1].
One of the outcomes noted in the Nurses’ Health Study was that there is a gradient of coronary risk, with the heaviest category of women having a 3-fold increased risk for CVD compared with lean women [34]. Much evidence has focussed on the distribution of fat with a more android morphology (apple) representing a higher cardiac risk than a more gynaecoid (pear) shape [35]. In general, skin-fold measurements
Exercise and physical activity
In a prospective observational study, it was found that a lower level of fitness was associated with a 4.7-fold increased risk of myocardial infarction and stroke, independent of other vascular risk factors [37]. The reported beneficial effects of exercise on CVD risk profile are less marked in women than in men, with smaller increases in HDL and weight loss resulting from similar exercise training [38]. Nevertheless, in the Nurses’ Health Study, two aspects were particularly important: brisk
Stress
The general public has tended to associate psychosocial stress and acute stress with myocardial infarction or stroke. In addition, the saying that she/he died of a broken heart has increased in popularity because of the increasing number of patients, mainly women, being referred for hospital treatment with severe heart failure after having experienced an extremely stressful event. Because the end-systolic left ventriculogram looks like a ‘tako-tsubo’, which is used for trapping octopuses in
Alcohol
While a moderate intake of alcohol may be protective, too much is deleterious [45], [46].
The grade of evidence is poor because of the problems in undertaking placebo-controlled studies. In addition, the control group may include ex-alcoholics who are now teetotallers.
The type of alcohol is not as important as drinking patterns. A low-to-moderate regular daily intake can be protective, while binge drinking can be harmful to the heart and the liver.
Recommendations are difficult but there is no
Diet
The beneficial effects of the Mediterranean diet, which has a high proportion of fruit and vegetables, on total cholesterol, LDL-cholesterol, blood pressure and MI are well known [47]. In the secondary prevention Lyon Heart Study, 600 women and men were randomised to the Mediterranean diet or to a control group, and after 27 months a significant difference was found in mortality and morbidity for CVD as well as total mortality in favour of the Mediterranean diet [48].
The mechanisms behind these
Conclusion
Because most deaths from CVD can be prevented, it is very important that all health professionals as well as women themselves are aware of and know about it.
It is the most common cause of death in both sexes and that there are gender-specific differences in the disease. CVD presents later in women who are therefore older and more likely to suffer from co-morbidities such as diabetes and hypertension.
Campaigns such as the World Heart Federation's ‘Go Red for Women’ are very important to spread
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